Pediatric Sleep Apnea: Tonsils, Adenoids, and CPAP Explained

When a child snores loudly, stops breathing for a few seconds during sleep, or wakes up gasping, it’s not just noise-it’s a sign something serious might be happening. Pediatric obstructive sleep apnea (OSA) affects 1 to 5% of all children, mostly between ages 2 and 6, when their tonsils and adenoids are largest relative to their airways. Left untreated, this isn’t just about poor sleep. It can lead to learning problems, behavioral issues, slow growth, and even heart strain over time.

Why Tonsils and Adenoids Are the Main Culprits

In kids, enlarged tonsils and adenoids are the #1 cause of obstructive sleep apnea. These are soft tissues at the back of the throat and nose that help fight infections. But when they grow too big-often after repeated colds or allergies-they block the airway while the child sleeps. Unlike adults, where obesity is the main issue, kids usually have OSA because their airways are physically squeezed shut by swollen tissue.

Dr. David Gozal, a leading pediatric sleep expert, found that removing just one (tonsils OR adenoids) often isn’t enough. Both need to come out because OSA isn’t caused by one swollen tissue-it’s the combined blockage. That’s why adenotonsillectomy (removing both) is the standard first step in treatment.

Adenotonsillectomy: The First-Line Treatment

The American Academy of Pediatrics and the American Thoracic Society both agree: for otherwise healthy kids with enlarged tonsils and adenoids, surgery is the best starting point. Success rates? Between 70% and 80% in kids without other health issues.

The procedure is done under general anesthesia. Most kids go home the same day. Recovery takes about a week to two, with soft foods and rest required. Pain is common but manageable. Some hospitals now offer partial tonsillectomy, where only part of the tonsil is removed. This reduces bleeding, pain, and recovery time by up to 30%-though it’s not available everywhere.

But surgery doesn’t always fix everything. Studies show 17% to 73% of children still have sleep apnea after surgery, especially if they’re overweight, have craniofacial differences, or suffer from neuromuscular conditions. That’s why follow-up sleep studies are critical. The American Thoracic Society recommends another sleep test 2 to 3 months after surgery to make sure the airway is truly open.

What If Surgery Doesn’t Work-or Isn’t an Option?

Not every child is a good candidate for surgery. Kids with Down syndrome, cerebral palsy, or severe obesity often have airway problems that aren’t solved by removing tonsils alone. That’s where CPAP comes in.

CPAP (Continuous Positive Airway Pressure) uses a small machine connected to a mask worn over the nose or face. It blows gentle, steady air into the throat to keep the airway open all night. For kids, pressure settings are usually between 5 and 12 cm H₂O, carefully adjusted during a sleep study to find the perfect level.

CPAP is highly effective-85% to 95% of kids see their breathing interruptions disappear when they use it consistently. But here’s the catch: kids hate wearing masks. About 30% to 50% of children struggle to use CPAP every night. Why? The mask feels strange, it’s uncomfortable, they get claustrophobic, or it leaks air and wakes them up.

Success with CPAP depends on fitting. Pediatric masks are smaller, softer, and come in different styles-nasal pillows, full-face, or hybrid. Many families need 2 to 8 weeks to get used to it. And because kids grow fast, masks must be checked and replaced every 6 to 12 months. Mayo Clinic experts say proper fitting makes all the difference. A well-fitted mask doesn’t just work better-it’s easier to live with.

Other Treatments: When Surgery and CPAP Aren’t Enough

Some kids need more than surgery or CPAP. For those with narrow palates, orthodontists can use rapid maxillary expansion. This device gently widens the upper jaw over 6 to 12 months, creating more space for the tongue and airway. Success rates? Around 60% to 70% in kids with true palate narrowing.

For milder cases, doctors sometimes prescribe inhaled corticosteroids-nasal sprays like fluticasone. These reduce inflammation in the adenoids and tonsils. Studies show 30% to 50% improvement in breathing after 3 to 6 months of daily use. It’s not a cure, but it can delay or even avoid surgery in some cases.

Newer options are emerging. Leukotriene blockers like montelukast (usually used for asthma) are being tested to shrink lymphoid tissue. Early results show promise, but it takes months to see results. Another option-hypoglossal nerve stimulation-is now FDA-approved for select pediatric cases. It’s a tiny implant that nudges the tongue forward during sleep to prevent blockage. But it’s only used in rare, complex cases where other treatments have failed.

How Do Doctors Know It’s Sleep Apnea?

You can’t diagnose this just by watching your child sleep. The gold standard is a polysomnography-an overnight sleep study. During this test, sensors monitor:

• Brain waves (to track sleep stages)
• Heart rhythm
• Oxygen levels in the blood
• Carbon dioxide levels
• Chest and belly movement (to see if breathing efforts are blocked)
• Muscle activity
• Airflow through the nose and mouth

A child with severe OSA might stop breathing 15 to 30 times per hour. That’s not snoring-that’s a medical emergency in the making.

What Happens If You Wait?

Many parents think, “My child will grow out of it.” But untreated pediatric OSA doesn’t just go away. Chronic sleep fragmentation and low oxygen levels affect brain development. Kids may struggle with attention, memory, and school performance. They’re more likely to be diagnosed with ADHD. Their growth hormone is suppressed, leading to slower height gain. And over time, the heart has to work harder, raising the risk of high blood pressure and heart problems later in life.

There’s no safe “wait and see” period for moderate to severe OSA. If your child snores, breathes through their mouth, has frequent night sweats, or seems tired during the day despite sleeping enough-it’s time to talk to a pediatric sleep specialist.

Choosing the Right Path: Surgery, CPAP, or Something Else?

There’s no one-size-fits-all answer. Here’s how most doctors decide:

Choosing the Right Treatment for Pediatric Sleep Apnea

Child’s Profile	Best First Treatment	Why?
Healthy, ages 2-6, large tonsils/adenoids	Adenotonsillectomy	80% success rate; fixes root cause
Obese child (BMI >95th percentile)	CPAP	Surgery often fails; CPAP works better
Child with Down syndrome or cerebral palsy	CPAP	Airway issues are neurological, not just anatomical
Mild OSA, no surgery candidate	Inhaled steroids or montelukast	Non-invasive; 30-50% improvement
Narrow palate, mouth breathing	Rapid maxillary expansion	Addresses structural issue long-term
OSA returned after surgery	CPAP or DISE-guided surgery	Find hidden blockages; CPAP fills the gap

Doctors at Yale and UChicago now use drug-induced sleep endoscopy (DISE) to see exactly where the airway collapses during natural sleep. This helps plan surgery more precisely-especially for kids who didn’t improve after tonsil removal.

What Parents Can Do

If your child is diagnosed with sleep apnea:

• Don’t delay treatment. The brain develops fastest between ages 2 and 6.
• Ask about partial tonsillectomy if surgery is recommended-it’s less painful.
• If CPAP is suggested, work with a pediatric sleep tech. Don’t give up after a bad week.
• Keep a sleep diary: note snoring, pauses, restlessness, daytime tiredness.
• Watch for signs of recurrence: snoring returns, bedwetting comes back, school performance drops.

Most kids who get the right treatment-whether surgery, CPAP, or a combination-go on to sleep normally, learn better, and grow stronger. The key is acting early, staying involved, and not accepting “it’s just a phase.”

Every child’s airway is different. What works for one might not work for another. The goal isn’t just to stop snoring-it’s to give your child the deep, restful sleep their growing body and brain need to thrive.